Seeking Calm on the Cancer Ward

Darren Hauck pour le New York Times sur les rives du lac Michigan.

Lorsque les gens choisissent d'avoir leur leucemie traitee de maniere agressive, c'est un grand engagement, plus encore que pour presque tous les autres cancers.

Avec cette therapie — trois jours de la daunorubicine de drogue, qui vient dans un rouge couleur si distinctifs qu'un de mes patients, un ancien pharmacien, utilise dans sa vie professionnelle comme colorant pour les plastiques, et sept jours de la cytarabine de drogue, qui est infusee de facon continue pendant 168 heures — nous leur offrons la chance de guerir d'une maladie se deplacant comme une trainee de poudre avec une bonne brise derriere elle a la hauteur de la secheresse.

L'offre peut considerer comme une aubaine faustienne, cependant. En retour, vient la possibilite tres reelle de la mort de notre traitement, ainsi que l'immersion dans une sorte de purgatoire d'une hospitalisation, une duree de quatre a six semaines. Nous plaisantent avec nos patients que nous aimons ennuyeux — c'est, en fait, un ideal medical que nos patients se plaignent de rien de plus que l'ennui au quotidien. Mais le courage psychologique qu'il faut pour supporter cette experience est remarquable, et il y en a peu qui peut preparer une personne pour elle.

Nous faisons nos tours en tant que groupe, infirmieres, assistants medecins, residents, fellow, un pharmacien, un gestionnaire de cas, moi et observateurs supplementaires de temps en temps. Il peut etre tout a fait absurde, vraiment, ce troupeau tonitruant, marchant lentement dans le couloir de l'unite de la leucemie, s'arretant a chaque fois une porte. Il y a quelques semaines, quand j'assistais au service de la leucemie, nous sommes arrives a notre huitieme patient de 25, un homme de 72 ans, dont la leucemie a persiste malgre notre premier tour de la chimiotherapie, alors nous lui avons donne plus. C'est maintenant le jour de son 36e dans l'hopital et sa numeration globulaire a montre aucun signe de retablissement, une terre en friche de la vacuite.

Quelques-uns d'entre nous, est entre dans sa chambre, ou sa femme etait assise dans un fauteuil de son lit, lisant. Elle leva les yeux et nous a donne un demi-sourire comme nous jeta un regard sur lui. Ses feuilles ont ete tires completement au-dessus de sa tete et puis caches sous elle, creation de l'image d'un cocon blanc amidonne.

? Ne crains pas lui. Il dort toujours comme ca,"dit-elle. ? Sur le navire, le canape ou il s'est repose etait directement sous un vent et c'etait le seul moyen qu'il pourrait jamais saisir toute deroulait ?. Il a remue et tire les feuilles vers le bas, en louchant contre les lumieres de la piece.

Il etait capitaine d'une peniche qui a traverse les grands lacs, transport de minerai de fer pour les acieries, a l'epoque ou les acieries etaient encore ouvertes et controlee de la Steinbrenners beaucoup de ce commerce. Il a dirige ces batiments massifs de l'arriere (? arriere ?, il aimait a rappeler a nous terriens), regarder a travers les terrains de deux football de leur longueur.

? Il serait parti de mars a octobre, ? a declare son epouse. ? J'etais un des veuves lac! ? Elle se mit a rire, mais elle-meme arrete rapidement, realisant le surnom menacee de devenir une realite. "Mais je savais a quoi je m'embarquais. Son pere etait un capitaine de navire, trop, donc ma belle-mere m'assit devant le jour de notre mariage afin de me preparer. ?

J'ai demande ce que c'etait comme aller de huit mois sans voir les uns les autres.

? J'ai manque de lui, mais nous nous rencontrerions tous les mois ou deux, ? mon patient Choru, maintenant eveille.

? J'ai suivi le navire, ? a ajoute son epouse. "Je savais quel jour ils enoncerait de Duluth et environ quand ils recevrait dans Chicago. Donc je serait pile les enfants dans la voiture et nous allions le voir. Nous aurions 24 heures comme une famille, mais si nous avons ete chanceux, et il y avait un probleme de maintenance sur le bateau, parfois, nous obtiendrions 36. ? Elle sourit a la memoire. ? Mais surtout, il y avait beaucoup d'attente. ?

Mon patient a dit: ? il s'est ameliore lorsque les enfants s'en alla au College. Puis elle pourrait me rejoindre sur le navire pendant deux semaines a la fois. ? Il fit un geste pour une photo sur son mur, du soleil levant sur un plan d'eau dans un ciel sans nuage. ? C'etait beau, vraiment, vu que tous les jours. ?

? Beautiful ?, fait echo a sa femme. Tout le monde dans la salle etait encore, penser a l'etendue d'eau, les milles, qu'il avait deja couvert et ce qui les attendait.

? Donc, je suppose qu'il n'y a aucun changement dans ma numeration globulaire? ? a demande a mon patient.

? Nope, pas encore, ? repondis-je. ? Mais ils pourraient ameliorer tous les jours maintenant. ?

? C'est O.K., ? dit-il. "Nous ne sommes pas presses. Venez nous voir demain."

Sa femme dit au revoir et retourna a son livre, que nous avons quitte sa chambre, les eaux calmes, l'air sans brise.

Dr Mikkael Sekeres est directeur du programme de leucemie a la Cleveland Clinic.

View the original article here

Obstacles for Pregnant Women Seeking Dental Care

In pain because of infected teeth, Luatany Caseres, 34, then a factory worker in Durham, N.C., was desperate to see a dentist.

At an emergency dental clinic that treats the uninsured, a receptionist told Ms. Caseres that the schedule was full. When she returned a second time in still greater pain, the receptionist told her, “I can’t get you seen.” On her third visit, Ms. Caseres’ swollen cheek bulged as if a lollipop were stuck there. Still, she was told that she would have to wait.

Why? “It was because I was pregnant,” Ms. Caseres said. She was in her second trimester, and the receptionist said she needed a doctor’s note before the office would consider treating her.

Finally, Ms. Caseres found Dr. George Soung, a fourth-year dental student who was trained in a new prenatal program at the University of North Carolina at Chapel Hill. By that time, two premolars had broken to the gums, exposing nerves. Her pain was so acute she was bedridden, taking sleeping pills and painkillers.

Dr. Soung extracted Ms. Caseres’s two abscessed teeth at once, because a far-gone infection could spread to the jaw or even throughout the body. “This wasn’t something that popped up a week ago,” he said. “Nobody would treat her.”

Too many pregnant women like Ms. Caseres are not getting timely dental care, experts say. There are plenty of reasons: Some dentists are reluctant to treat pregnant patients, in no small part because of outdated thinking. OB-GYNs too often fail to check for oral problems and to refer women to dentists. And many women fail to seek out oral care or mistakenly think it’s dangerous, even though pregnancy itself may lead to gum inflammation.

The problem among dentists is decades old. Many “were taught in dental school that you can’t treat a pregnant woman,” said Dr. Renee Samelson, a professor of obstetrics and gynecology at Albany Medical Center, who was an editor of the first guidelines on oral health in pregnancy, which were published by the New York State Department of Health and advised on two more sets of guidelines. Dentists simply erred on the side of caution, she added: “There was no evidence of harm.”

Today, although dental treatment during pregnancy is considered beneficial, some dentists still hesitate to see pregnant women, because they fear litigation or harm to the fetus, or their knowledge of appropriate care lags behind the current evidence. One 2009 survey of 351 obstetrician gynecologists nationwide found 77 percent reported their patients had been “declined dental services because of pregnancy.”

“A lot of dentists still fear treating pregnant women, and think, ‘What happens if I have to do an X-ray?’ or ‘What happens if I give antibiotics or local anesthesia?’” said Dr. Howard Minkoff, the chairman of obstetrics and gynecology at Maimonides Medical Center in Brooklyn. “None of these are legitimate reasons not to provide appropriate care for women.”

Since 2006, a few state organizations and dental associations have issued practice guidelines declaring that dental care is safe and effective at any stage of pregnancy, including diagnostic X-rays, cavity restorations and root canals.

OB-GYNs should check for bleeding gums or oral infection and refer a patient to a dentist if her last visit was longer than six months ago, according to the first national consensus statement on dental care during pregnancy, published in September by the National Maternal and Child Oral Health Resource Center at Georgetown University.

The statement advised dentists to provide emergency care in any trimester. OB-GYNs can be consulted, as necessary, if a pregnant patient is diabetic or hypertensive, or if general anesthesia is required.

Dr. Sally Cram, a periodontist in Washington, and a spokeswoman for the American Dental Association, said dentists she knows provide complete care. She added, “In the last 10 to 15 years, a lot of dentists have promoted the importance of pregnant women having regular cleanings.”

Delaying oral care can have serious consequences. Gingivitis, or gum inflammation, affects 60 to 75 percent of pregnant women, and left unchecked, it can become periodontal disease. Untreated periodontal disease can lead to tooth loss. And a mother with active tooth decay can spread cavity-causing bacteria to her child through saliva, perpetuating poor oral health.

Pregnant women with dental pain also may self-medicate inappropriately. In a March 2001 letter to the New York State Department of Health, a doctor described a patient who was unable to get urgent care for her abscessed teeth in upstate New York. She took such excessive doses of Tylenol that she developed acute liver failure, and the fetus died. That prompted the drafting of new state guidelines.

Still, some OB-GYNs do not address oral health during visits with pregnant women, an oversight that angers some dentists. “If you take your dog to the vet, the first thing they do is look in their mouth,” said Dr. Nancy Newhouse, a periodontist in Independence, Mo., and the president of the American Academy of Periodontology.

Many pregnant women simply don’t seek dental care, perhaps out of misplaced fear or neglect. Some states offer dental Medicaid benefits to low-income expectant mothers, for example, but utilization rates are low. Only 28 percent of eligible women seek and receive services in Oklahoma. In New York, 41 percent of pregnant women on Medicaid visited dentists in 2010, up from 30 percent in 2006.

Such a multifactorial problem requires a coordinated effort between OB-GYNs and dentists to reach mothers-to-be, said Dr. Stefanie Russell, a dentist and an epidemiologist at New York University. But for women with low-risk pregnancies, she said, “things will change when women realize dental care is their right during pregnancy.”

Deborah Acosta contributed reporting.

Leave your questions on dental care and pregnancy in the comments, and reporter Catherine Saint Louis will answer a selection of them.

View the original article here